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`SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OPFICE-,dSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .7-2-119 � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application- is hereby made- to the San Joaquin Local Health District,for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules" an.d Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 10701 E. Copperopolis Rd. CENSUS TRACT <br /> t <br /> Owner's Name Robert Cassidy Phone 462 2170 <br /> Address 90 N. Tulsa City Stockton. <br /> J A.• aamer . 272 3 477 1858 <br /> Cotttractor s Nam ThlhCoLicense 4� � Phone <br /> TYPE OF WORK..(Check): NEW WELL / / DEEPEN / / RECONDITION /_� DESTRUCTION /"T <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> m Other / / <br /> t <br /> DISTANCE TO NEAREST. SEPTIC TANK•. SEWER LINES - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT-1-1$ 'OTHER .- <br /> m INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C> <br /> Industrial Cable Tool Dia. of Well Excavation 10 tfleho <br /> . <br /> Domestic/private Drilled Dia. of Well Casing 6 inc <br /> m Domestic/public Driven Gauge of Casing ' .109 (� <br /> Irrigation Gravel. Pack . Depth-of-Grout- Seal. 50 ft. <br /> Other ' Rotary Type of Grout Cement <br /> " Other Other Information <br /> PUMP INSTALLATION; Contractor <br /> -.Type of Pump .r H.P. <br /> f <br /> PUMP REPLACEMENT- / / State Work Done <br /> i,PUMP-,REPAIR—;-,- �. �- . <br /> / / State=-Work-Done <br /> ,)ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> None Describe Material and Procedure <br /> I hereby agree to comply with all 1aws­and, regulatibns of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well., I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. ���� �� <br /> SIGNED 9 .L�ti, " ' TITLE,CJ� . ' ' Com:-. <br /> (DRAW PLOT PLAN ON REVERSE SIDE) V <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �/� DATE I/ -7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT NSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY ATE PECTION BY DATE 4,2 <br /> CALL FOR A GROUT I SPECTION .PRIOR TO GROUTING AND FINAL INSPECTION <br /> E H 1426 7/72 1M <br />